Last week, we posted a statement from four transgender advocacy organizations on the American Psychiatric Association’s ongoing efforts to update the Diagnostics and Statistical Manual for its fifth edition (DSM-V). This week, we have two statements from the APA. The first one is about the DSM revision process, and the second one is about Kenneth Zucker’s participation on the DSM workgroup.

The American Psychiatric Association has received inquiries about the DSM-V process, particularly concerns about the Sexual and Gender Identity Disorders Work Group. The APA recognizes that this work group and others will address difficult and sometimes controversial issues. The APA’s goal is to develop a diagnostic manual that is based on sound scientific data, but also sensitive to the needs of clinicians and their patients. To this end, the APA has created a process that involves opportunities for review and input from persons with varied backgrounds and opinions.

Thirteen DSM-V work groups have been established to review all existing diagnostic categories in the current DSM. Individual work groups may propose revisions to existing disorder criteria, inclusion of new disorders, removal of existing disorders, or no changes to a disorder or its criteria. They may also propose revisions to the text that accompanies the criteria for each disorder. The Sexual and Gender Identity Disorders Work Group, chaired by Kenneth J. Zucker, Ph.D., has three subworkgroups:

Gender Identity Disorders, chaired by Peggy T. Cohen-Kettenis, Ph.D.

Paraphilias, chaired by Ray Blanchard, Ph.D.

Sexual Dysfunctions, chaired by R. Taylor Segraves, M.D., Ph.D.

Each subworkgroup meets regularly, in person or on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are developed and then investigated through literature reviews and analyses of existing data. They also may further test research questions in field trials involving direct data collection. Because the work groups are limited in size, they may request outside advisors to assist them in these tasks, and to provide reviews and comments from other perspectives. Finally, in order to invite comments from even wider communities of researchers, clinicians, and consumers, the APA launched a web site in 2004, on which these groups can submit questions, comments and research findings, which are then distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses and clinical expertise, the subworkgroups will develop draft DSM-V diagnostic criteria. After a period of comment, the subworkgroups will review submitted questions, comments and concerns. The final draft of DSM-V will be submitted to APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. The final, approved DSM-V is expected to be released in May, 2012.

In summary, the DSM-V development process was constructed to achieve a thorough, balanced review of scientific data, with multiple levels of approval required, and opportunities for input from stakeholders. It is important to recognize that the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines. The APA is aware of a need for more scientific and clinical knowledge about the best medical and psychiatric care for individuals with Gender Identity Disorder. To address this need, the APA Board of Trustees voted to create a Task Force to review the scientific and clinical literature on GID treatment. The members of this Task Force will be appointed shortly.

Kenneth J. Zucker, Ph.D., C.Psych., the Chair of the DSM-V Sexual and Gender Identity Disorders work group, is a widely respected and pre-eminent scholar in the world of academic sexology research. As Chair of the work group for Sexual and Gender Identity Disorders, Dr. Zucker’s role is to coordinate and facilitate the work of the three sub-work groups addressing Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders. Further information on the DSM-V development process can be found at [this web site].

Dr. Zucker has published 97 peer-reviewed journal articles, 48 book chapters, and a landmark textbook. His published work addresses psychosexual differentiation and its disorders, based on a wide range of empirical research studies on children and adolescents with gender identity disorder, with a focus on diagnosis and assessment, and their associated behavioral and psychological distress. As the current Editor of Archives of Sexual Behavior, the premier human sexuality research journal, he also has a wide familiarity with the disparate areas of sexual dysfunctions and paraphilias. Since 2001, he has been the Psychologist-in-Chief at the Centre for Addiction and Mental Health (CAMH), is a Professor in the Departments of Psychiatry and Psychology at the University of Toronto, and is on the Scientific Staff (Division of Child Psychiatry) at the Hospital for Sick Children. He was the President of the International Academy of Sex Research in 2005-2006.

Dr. Zucker and his service team at CAMH in Toronto have the longest standing research-clinical service for children and youth with gender identity problems in North America. Since the mid-1970s, Dr. Zucker and his team have evaluated over 900 children and youth with gender identity issues. Dr. Zucker is one of the few researchers who is doing long-term follow-up of the patients he has treated.

The philosophy of Dr. Zucker’s team is to provide client-centered care that maximizes benefit and minimizes harm to each child or youth. The goal of treatment is a well-adjusted youth, regardless of ultimate gender identity or sexual orientation, who feels she or he has been genuinely helped by her or his healthcare providers. Dr. Zucker has offered a variety of treatment options, understanding that options may vary greatly with the age of the client. For younger clients, therapy options include helping the child to overcome discomfort with his or her body, i.e., helping clients learn to live comfortably in their natal sex. Diagnosis and treatment of other problems that may be present, such as anxiety, depression, or substance abuse are also available, as are services for family members.

For adolescent patients (including those who first came to the clinic as young children), Dr. Zucker follows the Standards of Care Guidelines of the World Professional Association for Transgender Health. The treatment options include helping patients make a satisfactory transition to the opposite sex, including the institution of hormonal treatment to facilitate transition. In some cases, treatment may include helping an interested adolescent obtain sex-reassignment surgery.

For all patients, regardless of age, the focus of therapy is the patient’s gender identity, not the patient’s sexual orientation. Dr. Zucker’s therapeutic approach has no relationship to so-called reparative or sexual conversion therapies that attempt to change homosexual orientations to heterosexual ones. The goal of his therapy is the opposite of conversion therapy in that he considers well-adjusted transsexual, gay, lesbian or bisexual youth to be therapy successes, not failures.

The American Psychiatric Association has convened several panels to discuss revisions to the Diagnostics and Statistical Manual (DSM), which is currently in its fourth edition (DSM-IV). It’s a standard practice for the APA to revise the manual every decade or so in order to incorporate knowledge generated by more current research.

The APA has begun the work of compiling the data for DSM-V, and that process has sparked several strange rumors around the Internet that really didn’t ring true with me. According to a few of these rumors, the American Psychiatric Association (APA) is poised to either reinstate homosexuality in the Diagnostics and Statistical Manual (DSM), or that the APA was going to decide to approve of sexual reorientation therapy. There is nothing however to suggest that anything like that will be happening.

But most of these rumors surround the diagnosis of Gender Identity Disorder (GID), which is of particular interest to the transgender community. These rumors are centered around two researchers who have been appointed to some of the working groups: Kenneth Zucker, who chairs the Sexual and Gender Identity Disorders work group, and Ray Blanchard, who chairs the Paraphilias subworkgroup under Zucker.

To understand transgender people’s concern about these two appointments, some background is in order. Kenneth Zucker and Ray Blanchard are associated with the Centre for Addiction and Mental Health in Toronto, Canada. This center resulted from the merger of four mental health centers, one of which was the Clarke Institute of Psychiatry. The Clarke Institute was the referral agency for transgender clients who wanted to surgically transition.

Many transgender clients found their treatment in the hands of the Clarke Institute degrading and offensive, feelings which were greatly magnified by the Institute’s main mission of treating sex offenders. Transgender clients often describe inappropriate and degrading tests and experiences at the institute. In fact, feelings run so deeply about the Clarke Institute that some transgender advocates have dubbed it “Jurassic Clarke.”, while others append the adjective “notorious” in front of the Institute’s name so routinely that one might be tempted to think that its official name was “The Notorious Clarke Institute.”

Because of the Clarke Institute’s history, virtually anything emanating from the Centre for Addiction and Mental Health is suspect among the transgender community, and those suspicions often radiate to the rest of the LGBT community.

Associations with the Clarke Institute however isn’t the only source of transgender advocates’ concerns. Also controversial are some of Blanchard’s theories on MtF transgender etiology that he calls “autogynephilia,”which many people find deeply offensive and off the mark. (Blanchard, on the other hand, is a leading researcher into what he believes to be the biological causes of male homosexuality.) Also controversial is Zucker’s approach to treating transgender clients, which involves counseling the client to take on behaviors and attitudes which are considered to be more socially appropriate to that person’s biological sex. This is an approach which raises alarm bells among gays and lesbians who recognize the parallels to sexual reorientation therapies, which may be the source of the rumors concerning homosexuality and sexual reorientation therapy that I mentioned earlier.

Today, we have a statement from four Transgender advocacy groups, which will hopefully provide some clarification on Zucker’s and Blanchard’s role in the DSM-V revision.

On May 1, 2008, the American Psychiatric Association (APA) announced the composition of work groups to review scientific advances and research-based information to develop the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The composition and scope of the work group on Sexual and Gender Identity Disorders and two subgroups are of great interest to transgender people and therefore to our organizations.

Though no consensus exists among transgender people about whether and how a GID diagnosis should be in the DSM-V, there is certainly agreement that decisions made by the APA about transgender and gender non-conforming people will deeply affect the lives of millions of transgender adults, adolescents and children.

We have met with and strongly encouraged the APA to closely adhere to its stated commitment to scientific process regarding diagnosis of transgender people. We are confident that a fair, unbiased review of current knowledge can result in a DSM-V that can move society toward a more rational and humane understanding of transgender people.

We encourage our transgender brothers and sisters to approach this issue with thoughtful consideration of all available information. To that end, we encourage transgender people and allies to remember that:

The naming of this working group on May 1 was not the commencement of advocacy around rethinking or revision of the GID diagnosis. Thoughtful advocates, within and without the APA, have been working on this issue for several years and they will continue to do so for several more, through at least 2012 when the DSM-V is finalized. We look forward to strengthening our relationships and positive communication channels with the many APA-affiliated professionals who are knowledgeable and understanding of transgender issues.

It is inconceivable that in the 21st century any credible scientist or medical professional would recommend any discredited treatment that would attempt to change a person’s core gender identity or sexual orientation. Such treatments have no empirical basis and are harmful. Importantly though, the DSM consists of diagnoses and not treatments. As such, the DSM-V will not offer any treatment recommendations for transgender people of any age.

The APA has created several mechanisms for thoughtful input into the DSM revision process from mental health professionals as well as laypeople affected by the DSM. We encourage transgender people and allies, especially mental health professionals, to utilize these systems to appropriately impact the process. In particular the APA has created a website through which written comments can be submitted. Additionally, as the DSM-V development process advances, working groups are charged with seeking the counsel and input of various advisers who will be selected from various clinicians, academics and other stakeholders. We will advocate for the inclusion of fair-minded advisors who are committed to providing only scientific, fair, reasonable and humane input. We are hopeful that these systems will help provide sufficient information to assure a fair and scientific process for the creation of the DSM-V.

Public acceptance of transgender people and anti-discrimination protections have been advancing swiftly. This is in large part due to scientific and medical advances, but also to the assertive, vigilant and intelligent activism of thousands of transgender people and our allies. While transgender people’s history with the psychiatric and medical professions has been, at times, fraught with misunderstanding and tainted by bigotry, we are optimistic that current and developing scientific research and clinical data will further the understanding of transgender issues among health care professionals and the public.

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